...trudging into the distance in the bleeding stinking mad shadow of Jesus...the Lord out of dust had created him, had made him blood and nerve and mind, had made him to bleed and weep and think, and set him in a world of loss and fire... --Flannery O'Connor

My old friend Lucifer came / Fought to keep me in chains / But I saw through the tricks / Of six-sixty-six --Johnny Cash

Anne's essay is a meditation on how "depression" has become a catch-all diagnosis for a range of ills that technically don't qualify for the DSM diagnosis of Major Depressive Disorder. The reason this is important, as Anne points out, is that if we don't have the diagnosis right then we can't get the prescription right. Specifically, the "disease model" behind the DSM Major Depressive Disorder diagnosis is ill-equipped to capture the psychic pain and relational distress that arise not from brain pathology but from the failures of social support networks.

From Anne's article:

“Depression” [now] seems to signify social ills for which we have no solution, from violent, homicidal behavior, to health illiteracy, to our culture’s neglect of the elderly. Constructing societal deficits as a medical problem does everyone a disservice—because treatment specific for depression won’t work for people who don’t really have depression. People who need social support can be expected to benefit most from programs that provide social support—not from psychiatrists.

The patient with bona fide depression will benefit from treatment with antidepressants or proven psychotherapies. For the lonely great-grandmothers, the junk food addicts, and the violent paraplegics, there has to be another form of intervention. We must turn from the inappropriate use of the disease model of emotional distress and understand that individuals’ psychological pain arises within social systems as well as within their own brains.

I think that's key. "The psychological pain [that] arises within social systems." By calling this pain "depression" we're often blaming the victim rather than attending to our failure, the failure of our social systems. How we fail each other as friends, family members, neighbors, parishioners, citizens and as fellow travelers on the journey through this vale of tears.

Anne's essay concludes:

Using the word “depression” to describe inexplicable or violent behavior sends two false signals: First, that society has no obligations with regard to our happiness—because misery is a medical problem—and second, that a depressed person is in danger of committing abhorrent acts.
Depressed people need help. “Depressed” people do, too—but not the same kind.

19 thoughts on “Misery As a Medical Problem?”

I agree; Anne Skomorowsky's article IS fascinating, and appreciated. And so is your last sentence!

This is a daunting challenge that the church cannot ignore, being that the church, like family, often has played a part in how one seeks, or refuses to seek, help for depression. Notice, I did not say cause, since I am convinced that bona fide depression is a sickness that afflicts certain people regardless of the circumstances around them. For these people, no amount of self affirmation exercises by themselves or positive affirmations from others, will bring about an actual cure. I believe the treatment, when it comes to the church, begins by ministers and individual Christians presenting self as one who can be trusted to recognize depression as the crippling disease that it is. There is a reason some people hurt themselves or attempt suicide; depression itself does not bleed or put you on your death bed, and it is the only way that some are able to say "I'm sick". Hearing others say time and time again, "Oh, you're OK", builds a deadly desperation.

As far as always being able to recognize the difference those who are actually depressed and others who are need of social support, that is always going to be a difficult task for laypeople like myself. But there is one thing I do believe all of us can begin to practice as we mature, and that is ATTENTIVENESS. I am not really sure if it because I am a late bloomer, or if it is something that comes easier as one makes the passage through middle age to senior, but you begin to watch people's faces more; their eyes speak much, much more than they can actually say.

Excellent points. I'd only add that I think the discussion of mental health as such needs to jettison the meme of the "problem individual" and the "maladjusted self" (which, I'm afraid, the counselling movement itself, at least during the second half of the 20th century, has helped to spread). "Problem" and "maladjusted" in relation to what? In relation to, i.e., in the context of, a society that itself suffers from a range of pathologies -- e.g., systemic poverty, institutional racism, mass incarceration. And that's why along with care you need critique -- as the pastoral needs the prophetic -- otherwise social support will not only be merely palliative, it will inevitably morph into forms of social control that sustain the status quo. To riff on Freud, for a civilization to nurture shalom, it must have its discontents.

I thought this article was SO insightful. Depression has become this catch all term that hides more than it illuminates, probably because it's so much easier to give someone an SSRI than it is to ask some hard questions of our society. (Not that I'm against SSRI's - for some people, that's what the situation requires.)

I lost someone close to me and have been in emotional and, often, physical pain for the last seven months. My personality has changed dramatically, I'm afraid of new people and experiences, I have trouble concentrating, I lost a lot of weight, I'm constantly exhausted. It all feels hopeless. As far as I can tell, the pain isn't going to go away anytime soon. At what point does grief become anxiety/depression? Sometimes it feels like it's not even really about that person anymore; this is just who I am now.

In my experience, the church is the last social institution to go for understanding organic depression or for those who desperately need a better support system. Often people who are clinically depressed have been advised to get off their meds and simply pray more, read the Bible, and attend church more often. Given our sometimes gross exaggerated emphasis on individualism, some are not sympathetic to others having personal problems. It appears to me at a distance that the co-pilot might have had a narcissistic personality disorder, feeling that only his issues were important and therefore disregarded the lives of 149 other innocent passengers. No magic pills can be taken to create empathy or remorse.

Truly depressed people don't have the emotional energy to plot a mass murder/suicide "grand gesture". Everything they have is focused on trying to appear "normal" when they are no longer sure what "normal" is and whether there is a possibility of their physic pain ending. The suicide (attempted or accomplished) comes out of the belief, an acceptance, that there will be no end and loved ones are honestly better off without them. The last desire to spare family years and years with a person who has only emptiness inside (from the depressed person's perspective) just doesn't jibe with "making a name for oneself" by plotting the murder of 149 people.

Yes, loss overpowers, dominates and beats you until you feel that is all you are. But you are still Anny, known, lifted up and remembered by many, many others now. No, it is not a cure; but I pray it is a thought that you can take to your bed to embrace you through the nights to come, until you are able to embrace the empty space. Then it belongs to you; not you to it.

The church MUST learn how to equip its congregants to be good friends to one another. If we can get that right, I think it could cover a multitude of ills. We need better friendships, NOT more therapists. (Of course each have their place.) A rigorous theology of friendship with practical resources for churches is a desperate need within the collective church, it seems.

I may be reading her wrongly, but it does appear that Anne posits only two plausible domains of explanation for "abhorrent acts:" either it is (1) a medical problem (which she of course disputes), or it is (2) a "failure of our social systems." The two domains have this in common: they are largely external to the individual, so that responsibility devolves to something or someone other than the person that actually committed the act. Below (or above), in the other comments, Kim takes option #2 a step further by defining abnormality down and implicating not only a failed social system but a fundamentally irredeemable one, with unmistakable political overtones. What if we were to admit a third possibility to the conversation, a domain residing within the individual, which we might term (roughly) "virtue" or "character?" Is volition a pure product of environment, or is it a complex brew?

I certainly don't mean to deny personal agency or responsibility, but I do want to place them, particularly in a culture of hyper-individualism, in the context of the social/political -- indeed, I should add, theologically, in the the context of "principalities and powers". And, yes, our social systems are "fundamentally irredeemable" this side of the eschaton, but that doesn't preclude, indeed it entails -- "Live tomorrow's life today!" (Brian Wren) -- working to erect signs of the kingdom, parables of shalom, in the broken world God is in the process of healing. As you say, a "complex brew".

parker palmer was particularly helpful to me in my deepest monents of depression last year. one thing of his memior stands out and still keeps me from being totally negative abt loss of all that pressious time to self hate and dispare is something a therapist observed of him that 'you seem to see depression as an enemy. Could you instead see it as an honest friend that helps you get down from your preconcieved inflated ego fantasy caracature of yourself and from the deconstructed ashes form an informed existential narration of self?'(not an exact quote).

Thanks, everyone. I did see a counselor for a few weeks and have been trying to find another in my current city (the situation involved moving). I hope it will be helpful. But that's one of the questions I've been wondering about- is it a psychological problem or "just" a difficult circumstance? The former is enticing because it suggests there's something wrong with me that can be fixed. If the diagnosis is simply that life is hard, well, there's not much you can do about that. Life will keep being hard.

I know depression comes in a lot of different forms, but yeah, the idea of attributing grand acts of violence to depression seems kind of absurd to me. Has the person who wrote that ever been depressed? My depressed self isn't capable of buying groceries on a regular basis, let alone staging an elaborate plot to murder a bunch of people. (Note because this is the internet and things get misinterpreted: I would definitely not be interested in murdering people even if I had more energy.)

you are loved tho you might not feel it. i felt nothing for most of last.year and dropped out of life. There doesn't seem to me to me one size fits all road to recovery tho if you lost someone or something tjat gave meaning to life it will take as long as.it takes to heal the grief from loss. It's normal to not function well after an emotional wounding; as normal as any class of trauma or disease is to a physical body. You are loved by a living god no matter what I think.

Absolutely true. I would just like to point out (what may be obvious) that having true depression and needing a social support network are not mutually exclusive. Friendship and other forms of social support are very important for people struggling with biological depression, just as they're important for anyone struggling with any kind of chronic illness. Unfortunately, in our society it's often precisely those people who are neglected and ignored. Most people are so freaked out by other people's suffering that they will avoid it any way they can. That may be the real reason we have so many psychiatrists - we as a society are basically outsourcing empathy. We don't want to deal with other people's pain unless we're being paid. I'm not knocking therapy - I've benefited from it - but too often I think we're just talking to someone in an office because our friends and relatives don't want to hear us. And if you can't afford $200 per hour and your insurance won't cover it, tough luck.